Background: There is growing appreciation that the staffing of intensive care units (ICUs) by physicians trained in critical care medicine (intensivists) can result in improved patient outcomes. Intensivist staffing of ICUs has now been endorsed and advocated by a number of high-profile public and private partnerships. However adoption of intensivist staffing by hospitals has been hampered by an array of factors including a shortage of intensivist physicians. Recruiting and retaining intensivists may be particularly challenging for smaller rural hospitals including many smaller facilities within the Veterans Health Administration (VA). In an effort to overcome a lack of available intensivists a growing number of hospitals have installed remote ICU monitoring systems. These systems typically combine high-speed videoconferencing with features of an electronic medical record (EMR) to connect the clinical care team and patients at the remote (physical) ICUs to intensivist physicians and nurses at a central monitoring center; using this technology it is possible for a single intensivist and two or three nurses to monitor upwards of one hundred patients distributed across multiple physical ICUs. Staff at the monitoring center can check vital signs and laboratory tests, write orders, and communicate via videoconference with the on-site clinical care teams at the physical ICUs about changes in the condition of individual patients. Despite rapid adoption of remote ICU monitoring by hospitals, rigorous empirical data about the impact of these systems are extremely limited. Objectives: The objective of this study is to take advantage of a unique natural experiment that will occur with the implementation of a remote ICU monitoring system in the eight ICUs (seven hospitals) within VISN 23 during calendar year 2010. Our primary objective will be to examine the impact of remote ICU monitoring on patient outcomes including mortality, ventilator acquired pneumonia, and ICU length of stay. Our secondary objectives are to develop a taxonomy for describing the nature of the recommendations made by the central monitoring center and to evaluate the cost of implementing the ICU monitoring system. Methods: This study will use a mixed-methods approach. First, we will use validated VA administrative and clinical data to assess the impact of remote monitoring on patient mortality, length of stay, and selected intermediate patient outcomes including ventilator acquired pneumonia (VAP) and catheter-related bloodstream infections (CR-BSI). For these analyses the intervention group will consist of consecutive patients admitted to the eight ICUs within VISN-23 where the remote ICU monitoring system will be implemented. The control group will consist of a cohort of patients admitted to eight control ICUs outside of VISN-23 that will not receive remote monitoring and are selected by propensity score matching. Second, we will develop a taxonomy for describing the nature of the recommendations made by the monitoring center staff and then use the taxonomy to characterize the types and relative frequency of therapeutic and diagnostic recommendations. Third, we will examine the start-up and maintenance costs associated with the implementation of the remote ICU monitoring program. Impact on VA: This evaluation will allow clinicians and administrators within the VA to understand the benefits and costs of implementing a remote ICU monitoring program.